Presentation, Treatment, and Outcomes of Vulnerable Populations With Esophageal Cancer Treated at a Safety-Net Hospital

Oesophageal cancer-specific mortality risk and public health insurance: Prospective cohort study from China

BACKGROUND

Oesophageal cancer is a significant health concern worldwide, with high incidence and mortality rates. In China, the disease burden is particularly high, accounting for a substantial proportion of oesophageal cancer cases and related deaths worldwide.

AIM

To explore the relationship between the mortality rate of oesophageal cancer patients and insurance type, out-of-pocket ratio, and the joint effects of insurance type and out-of-pocket ratio.

METHODS

The χ 2 test was used to analyze patients' demographic and clinical characteristics. Multivariate logistic regression, the Cox proportional hazard model, and the competitive risk model were used to calculate the cumulative hazard ratios (HRs) of all-cause death and oesophageal cancer-specific death among patients with different types of insurance and out-of-pocket ratios.

RESULTS

Compared with patients covered by basic medical insurance for urban and rural residents, patients covered by urban employee basic medical insurance for urban workers (UEBMI) had a 23.30% increased risk of oesophageal cancer-specific death [HR = 1.233, 95% confidence interval (CI): 1.093-1.391, P < 0.005]. Compared with patients in the low out-of-pocket ratio group, patients in the high out-of-pocket ratio group had a 25.80% reduction in the risk of oesophageal cancer-specific death (HR = 0.742, 95%CI: 0.6555-0.84, P < 0.005). With each 10% increase in the out-of-pocket ratio, the risk of oesophageal cancer-specific death decreased by 10.10% in patients covered by UEBMI. However, the risk of oesophageal cancer-specific death increased by 26.90% in patients in the high out-of-pocket ratio group.

CONCLUSION

This study reveals the relationships of the specific mortality rate of patients with oesophageal cancer with the out-of-pocket ratio and medical insurance types as well as their combined effects. This study provides practical suggestions and guidance for the formulation of relevant policies in this area.

Comparing cancer stage at diagnosis between migrants and non-migrants: a meta-analysis

BACKGROUND

Migrants face barriers accessing healthcare, risking delays in cancer diagnosis. Diagnostic delays result in later stage diagnosis which is associated with poorer cancer survival. This review aims to compare the differences in cancer stage at diagnosis between migrants and non-migrants.

METHODS

We conducted a systematic review and meta-analysis of three databases from 2000 to 2023 for studies conducted in OECD countries that compared stage at diagnosis between migrants and non-migrants. Meta-analysis compared odds ratios (OR) for early (stage I and II) stage at diagnosis. The Risk of Bias in Non-randomised Studies of Exposure tool was used to assess study quality.

RESULTS

41 of the 11,549 studies identified were included; 34 studies had suitable data for meta-analysis. Overall, migrants were significantly less likely to be diagnosed with early stage cancer compared with non-migrants (OR 0.84; 95% CI 0.78-0.91). This difference was maintained across cancer types, although only statistically significant for breast (OR 0.78; 95% CI 0.70-0.87) and prostate cancer (OR 0.92; 95% CI 0.85-0.99).

DISCUSSION

Published studies indicate that migrants are less likely to be diagnosed with early stage cancer. Variation by cancer type, study location and region of origin highlights the need for further research to understand these differences.

The impact of limited English proficiency on oncological outcomes in the United States: A systematic review

BACKGROUND

The increasing number of immigrants in the United States (U.S.) has resulted in more patients with limited English proficiency (LEP). LEP contributes to patient-provider language discordance, which may impact oncologic health outcomes.

OBJECTIVES

To assess the effects of LEP compared to English proficiency (EP) for oncological outcomes in adult cancer patients in the United States.

SEARCH METHODS

We searched MEDLINE (Ovid), the Cochrane Library (Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials), PsycINFO, CINAHL and Scopus from data inception to 26 January 2023. We also searched the reference lists and cited lists of included studies. Studies were limited to the United States and the English language.

SELECTION CRITERIA

We included retrospective and cross-sectional studies that analyzed one or more clinical outcomes (survival, readmission, length of stay, complications and discharge disposition) in LEP and EP cancer patients. Studies were eligible if they assessed cancer patients in the United States who were 18 years and older.

DATA COLLECTION AND ANALYSIS

Using a piloted, standardized data collection form, two non-blinded, independent reviewers extracted data in duplicate from studies meeting our inclusion criteria. Reviewers resolved discrepancies through discussion. We then performed a qualitative assessment of the findings.

MAIN RESULTS

We retrieved 2425 records from the database searches. We screened 1496 records by title and abstract and reviewed the full text of eight records. We retrieved 347 records from additional search methods and reviewed the full text of six records. We included 14 papers in total for analysis. The studies included 55,141 total patients and assessed outcomes in brain, oesophageal, head and neck, pancreatic and skin cancer. Our qualitative assessment demonstrated limited information on whether LEP impacted survival, complications and discharge disposition. We found no significant association between LEP and readmission or length of stay.

CONCLUSIONS

Studies assessing the impact of LEP and EP on the health outcomes of cancer patients are sparse and inconsistent in the measurements of outcomes and data reporting. The inconclusiveness of our study indicates that further standardized research is needed to assess the impact of LEP on the outcomes of cancer patients in the United States.

Racial Disparities in Head and Neck Cancer: It's Not Just About Access

OBJECTIVE

Medical literature identifies stark racial disparities in head and neck cancer (HNC) in the United States, primarily between non-Hispanic white (NHW) and non-Hispanic black (NHB) populations. The etiology of this disparity is often attributed to inequitable access to health care and socioeconomic status (SES). However, other contributors have been reported. We performed a systematic review to better understand the multifactorial landscape driving racial disparities in HNC.

DATA SOURCES

A systematic review was conducted in Covidence following Preferred Reporting Items for Systematic Reviews and Meta-analyses Guidelines. A search of PubMed, SCOPUS, and CINAHL for literature published through November 2022 evaluating racial disparities in HNC identified 2309 publications.

REVIEW METHODS

Full texts were screened by 2 authors independently, and inconsistencies were resolved by consensus. Three hundred forty publications were ultimately selected and categorized into themes including disparities in access/SES, treatment, lifestyle, and biology. Racial groups examined included NHB and NHW patients but also included Hispanic, Native American, and Asian/Pacific Islander patients to a lesser extent.

RESULTS

Of the 340 articles, 192 focused on themes of access/SES, including access to high-quality hospitals, insurance coverage, and transportation contributing to disparate HNC outcomes. Additional themes discussed in 148 articles included incongruities in surgical recommendations, tobacco/alcohol use, human papillomavirus-associated malignancies, and race-informed silencing of tumor suppressor genes.

CONCLUSION

Differential access to care plays a significant role in racial disparities in HNC, disproportionately affecting NHB populations. However, there are other significant themes driving racial disparities. Future studies should focus on providing equitable access to care while also addressing these additional sources of disparities in HNC.

Disparities and access to thoracic surgeons among esophagectomy patients in the United States

Esophagectomy is a complex operation with significant morbidity and mortality. Previous studies have shown that sub-specialization is associated with improved esophagectomy outcomes. We hypothesized that disparities would exist among esophagectomy patients regarding access to thoracic surgeons based on demographic, geographic, and hospital factors. The Premier Healthcare Database was used to identify adult inpatients receiving esophagectomy for esophageal and gastric cardia cancer, Barrett's esophagus, and achalasia from 2015 to 2019 using ICD-10 codes. Patients were categorized as receiving their esophagectomy from a thoracic versus non-thoracic provider. Survey methodology was used to correct for sampling error. Backwards selection from bivariable analysis was used in a survey-weighted multivariable logistic regression to determine predictors of esophagectomy provider specialization. During the study period, 960 patients met inclusion criteria representing an estimated population size of 3894 patients. Among them, 1696 (43.5%) were performed by a thoracic surgeon and 2199 (56.5%) were performed by non-thoracic providers. On multivariable analysis, factors associated with decreased likelihood of receiving care from a thoracic provider included Black (OR 0.41, p < 0.001), Other (OR 0.21, p < 0.001), and Unknown race (OR 0.22, p = 0.04), and uninsured patients (OR 0.53, p = 0.03). Urban hospital setting was associated with an increased likelihood of care by a thoracic provider (OR 4.43, p = 0.001). In this nationally representative study, Nonwhite race, rural hospital setting, and lower socioeconomic status were factors associated with decreased likelihood of esophagectomy patients receiving care from a thoracic surgeon. Efforts to address these disparities and provide appropriate access to thoracic surgeons is warranted.

Barriers and facilitators to surgical access in underinsured and immigrant populations

BACKGROUND

Marginalized communities are at risk of receiving inequitable access to surgical care. We aimed to examine the barriers and facilitators to access to surgery in underinsured and immigrant populations.

METHODS

A systematic review of disparities in access to surgical care was performed between January 1, 2000-March 2, 2022. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A convergent integrated approach was used to code common themes between studies.

RESULTS

Of 1315 publications, a total of 66 studies were included for systematic review. Eight studies specifically discussed immigrant patient populations. Barriers and facilitators to surgical access were categorized by patient and health systems related factors.

CONCLUSIONS

Established facilitators to improve surgical access are centered on patient-level factors while interventions to address systems-related barriers are limited and may be an area for further investigation. Research focused on access to surgery in immigrant populations remains sparse.

Association of Language Barriers With Perioperative and Surgical Outcomes: A Systematic Review

Importance

English language proficiency has been reported to correlate with disparities in health outcomes. Therefore, it is important to identify and describe the association of language barriers with perioperative care and surgical outcomes to inform efforts aimed at reducing health care disparities.

Objective

To examine whether limited English proficiency compared with English proficiency in adult patients is associated with differences in perioperative care and surgical outcomes.

Evidence Review

A systematic review was conducted in MEDLINE, Embase, Web of Science, Sociological Abstracts, and CINAHL of all English-language publications from database inception to December 7, 2022. Searches included Medical Subject Headings terms related to language barriers, perioperative or surgical care, and perioperative outcomes. Studies that investigated adults in perioperative settings and involved quantitative data comparing cohorts with limited English proficiency and English proficiency were included. The quality of studies was evaluated using the Newcastle-Ottawa Scale. Because of heterogeneity in analysis and reported outcomes, data were not pooled for quantitative analysis. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guideline.

Findings

Of 2230 unique records identified, 29 were eligible for inclusion (281 266 total patients; mean [SD] age, 57.2 [10.0] years; 121 772 [43.3%] male and 159 240 [56.6%] female). Included studies were observational cohort studies, except for a single cross-sectional study. Median cohort size was 1763 (IQR, 266-7402), with a median limited English proficiency cohort size of 179 (IQR, 51-671). Six studies explored access to surgery, 4 assessed delays in surgical care, 14 assessed surgical admission length of stay, 4 assessed discharge disposition, 10 assessed mortality, 5 assessed postoperative complications, 9 assessed unplanned readmissions, 2 assessed pain management, and 3 assessed functional outcomes. Surgical patients with limited English proficiency were more likely to experience reduced access in 4 of 6 studies, delays in obtaining care in 3 of 4 studies, longer surgical admission length of stay in 6 of 14 studies, and more likely discharge to a skilled facility than patients with English proficiency in 3 of 4 studies. Some additional differences in associations were found between patients with limited English proficiency who spoke Spanish vs other languages. Mortality, postoperative complications, and unplanned readmissions had fewer significant associations with English proficiency status.

Conclusions and Relevance

In this systematic review, most of the included studies found associations between English proficiency and multiple perioperative process-of-care outcomes, but fewer associations were seen between English proficiency and clinical outcomes. Because of limitations of the existing research, including study heterogeneity and residual confounding, mediators of the observed associations remain unclear. Standardized reporting and higher-quality studies are needed to understand the impact of language barriers on perioperative health disparities and identify opportunities to reduce related perioperative health care disparities.

Association between hospital safety-net burden and receipt of trimodality therapy and survival for patients with esophageal cancer

BACKGROUND

To examine the relationship between hospital safety-net burden and (1) receipt of surgery after chemoradiation (trimodality therapy) and (2) survival in esophageal cancer patients.

METHODS

The National Cancer Database was queried to identify 22,842 clinical stage II to IVa esophageal cancer patients diagnosed in 2004 to 2015. The treatment facilities were categorized by proportion of uninsured/Medicaid-insured patients into percentiles. No safety-net burden hospitals (0-37th percentile) treated no uninsured/Medicaid-insured patients, whereas low (38-75th percentile) and high (76-100th percentile) safety-net burden hospitals treated a median (range) of 8.8% (0.87%-16.7%) and 23.6% (16.8%-100%), respectively. Adjusted odds ratios and hazard ratios with 95% confidence intervals were computed, adjusting for patient, tumor, and treatment characteristics.

RESULTS

Compared to no safety-net burden hospital patients, high safety-net burden hospital patients were significantly more likely to be young, Black, and low-income. Age, female sex, Black race, Hispanic ethnicity, nonprivate insurance, lower income, higher comorbidity score, upper esophageal location, squamous cell histology, higher stage, time to treatment, and treatment at a community program or a low-volume facility were associated with lower odds of receiving trimodality therapy. Adjusting for these factors, high safety-net burden hospital patients were less likely to receive surgery after chemoradiation versus no safety-net burden hospital patients (adjusted odds ratio 0.77 [95% confidence interval 0.68-0.86], P < .0001); no difference was detected comparing low safety-net burden hospitals versus no safety-net burden hospitals (adjusted odds ratio 1.01 [0.92-1.11], P = .874). No significant survival difference was noted by safety-net burden (low safety-net burden hospitals versus no safety-net burden hospitals: adjusted hazard ratio 1.01 [0.96-1.06], P = .704; high safety-net burden hospital versus no safety-net burden hospitals: adjusted hazard ratio 0.99 [0.93-1.06], P = .859).

CONCLUSION

Adjusting for patient, tumor, and treatment factors, high safety-net burden hospital patients were less likely to undergo surgery after chemoradiation but without significant survival differences.

Disparities in Access to Thoracic Surgeons among Patients Receiving Lung Lobectomy in the United States

Objective: Lung lobectomy is the standard of care for early-stage lung cancer. Studies have suggested improved outcomes associated with lobectomy performed by specialized thoracic surgery providers. We hypothesized that disparities would exist regarding access to thoracic surgeons among patients receiving lung lobectomy for cancer. Methods: The Premier Hospital Database was used to identify adult inpatients receiving lung lobectomy from 2009 to 2019. Patients were categorized as receiving their lobectomy from a thoracic surgeon, cardiovascular surgeon, or general surgeon. Sample-weighted multivariable analysis was performed to identify factors associated with provider type. Results: When adjusted for sampling, 121,711 patients were analyzed, including 71,709 (58.9%) who received lobectomy by a thoracic surgeon, 36,630 (30.1%) by a cardiovascular surgeon, and 13,373 (11.0%) by a general surgeon. Multivariable analysis showed that thoracic surgeon provider type was less likely with Black patients, Medicaid insurance, smaller hospital size, in the western region, and in rural areas. In addition, non-thoracic surgery specialty was less likely to perform minimally-invasive (MIS) lobectomy (cardiovascular OR 0.80, p < 0.001, general surgery OR 0.85, p = 0.003). Conclusions: In this nationally representative analysis, smaller, rural, non-teaching hospitals, and certain regions of the United States are less likely to receive lobectomy from a thoracic surgeon. Thoracic surgeon specialization is also independently associated with utilization of minimally invasive lobectomy. Combined, there are significant disparities in access to guideline-directed surgical care of patients receiving lung lobectomy.

Impact of Patient Primary Language upon Immediate Breast Reconstruction After Mastectomy

BACKGROUND

Preoperative decision-making in patients who speak a primary language other than English is understudied. We investigated whether patient primary language is associated with differences in immediate breast reconstruction (IBR) after mastectomy.

PATIENTS AND METHODS

This retrospective observational study analyzed female patients undergoing mastectomy in the New Jersey State Inpatient Database (2009-2014). The primary outcome was the odds of IBR with a prespecified subanalysis of autologous tissue-based IBR. We used multivariable logistic regression and hierarchical generalized linear mixed models to control for patient characteristics and nesting within hospitals.

RESULTS

Of 13,846 discharges, 12,924 (93.3%) specified English as the patient's primary language, while 922 (6.7%) specified a language other than English. Among English-speaking patients, 6178 (47.8%) underwent IBR, including 2310 (17.9%) autologous reconstructions. Among patients with a primary language other than English, 339 (36.8%) underwent IBR, including 93 (10.1%) autologous reconstructions. Unadjusted results showed reduced odds of IBR overall [odds ratio (OR) 0.64, 95% CI 0.55-0.73], and autologous reconstruction specifically (OR 0.52, 95% CI 0.41-0.64) among patients with a primary language other than English. After adjustment for patient factors, this difference persisted among the autologous subgroup (OR 0.64, 95% CI 0.51-0.80) but not for IBR overall. A hierarchical model incorporating both patient characteristics and hospital-level effects continued to show a difference among the autologous subgroup (OR 0.75, 95% CI 0.58-0.97).

CONCLUSIONS

Primary language other than English was an independent risk factor for lower odds of autologous IBR after adjustments for patient and hospital effects. Focused efforts should be made to ensure that patients who speak a primary language other than English have access to high-quality shared decision-making for postmastectomy IBR.

Icotinib derivatives as tyrosine kinase inhibitors with anti-esophageal squamous carcinoma activity

Previous report showed that a variety of icotinib derivatives bearing different 1,2,3-triazole moieties, which could be readily prepared via copper (I)-catalyzed cycloaddition (CuAAC) reaction between icotinib and different azides, exhibited interesting activity against different lung cancer cell lines such as H460, H1975, H1299, A549 or PC-9. To further expand the application scope of the compounds and to validate the function of triazole groups in drug design, the anti-cancer activity of these compounds against esophageal squamous carcinoma (ESCC) cells was tested herein. Preliminary MTT experiments suggested that these compounds were active against different ESCC cell lines such as KYSE70, KYSE410, or KYSE450 as well as their drug-resistant ones. Especially, compound 3l showed interesting anticancer activity against these cell lines. The mode of action was studied via molecular docking, SPR experiments and other biochemical studies, and 3l exhibited higher binding potential to wild-type EGFR than icotinib did. In vivo anticancer study showed that 3l could inhibit tumor growth of cell-line-derived xenografts in ESCC. Study also suggested that 3l was a potent inhibitor for EGFR-TK pathway. Combining these results, 3l represents a promising lead compound for the design of anti-cancer drugs against ESCC.

Social determinants of health and treatment decisions in head and neck cancer

BACKGROUND

This study compares select social determinants of health (SDOH) with treatment modality selection and treatment completion in head and neck cancer (HNC) patients, to better understand disparities in health outcomes.

METHODS

A retrospective cohort study of HNC (n = 1428) patients was conducted. Demographic and disease-specific variables were recorded, including treatment modality selection and completion. Data were analyzed using two-sample t tests, chi-square, and Fisher's exact tests.

RESULTS

Primary language was significantly associated with treatment choice, where non-English speakers were less likely to choose treatment as recommended by the Tumor Board. Lower mean distance from the hospital (37.38 [48.31] vs. 16.92 [19.10], p < 0.0001) and a county-based higher mean percentage of bachelor degree or higher education (42.16 [8.82] vs. 44.95 [6.19], p < 0.0003) were associated with treatment selection.

CONCLUSION

Language, distance from the hospital, and education affected treatment selection in this study and may be useful in understanding how to counsel patients on treatment selection for HNC.

A narrative review of socioeconomic disparities in the treatment of esophageal cancer

The persistent challenges of disparities in healthcare have led to significantly distinct outcomes among patients from different racial, ethnic, and underserved populations. Esophageal Cancer, not unlike other surgical diseases, has seen significant disparities in care. Esophageal cancer is currently the 6th leading cause of death from cancer and the 8th most common cancer in the world. Surgical disparities in the care of patients with Esophageal Cancer have been described in the literature, with a prevailing theme associating minority status with worse outcomes. The goal of this review is to provide an updated account of the literature on disparities in Esophageal Cancer presentation and treatment. We will approach this task through a conceptual framework that highlights the five main themes of surgical disparities: patient-level factors, provider-level factors, system and access issues, clinical care and quality, and postoperative outcomes, care and rehabilitation. All five categories play a complex role in the delivery of high-quality, equitable care for patients with Esophageal Cancer. While describing disparities in care is the first step to correcting them, moving forward, we should focus on developing effective interventions to mitigate disparities, policies linking disparities to quality-of-care metrics, and delivery system change to enable minority patients to more easily access high volume centers.